Readability comparison of pro- and anti-HPV-vaccination online messages in Japan

Are we saying it right? Communication strategies for fighting vaccine hesitancy

Vaccine hesitancy is a multi-faceted phenomenon, deeply rooted in cultural, socioeconomic and personal background. Communication is deemed fundamental in fighting vaccine hesitancy. Medical communication should be accessible, relying both on an emotional approach and accurate information. Trained professionals should curate communication with the public.

Perspectives on childhood coronavirus disease vaccination in Japan and influencing factors

BACKGROUND

To support parental decision-making it is important to understand parents' perspectives on vaccination for their children and the factors that contribute to their vaccine hesitancy. There have been relatively few studies in this area in Japan, particularly with longitudinal and mixed methodologies.

METHODS

We used an explanatory sequential mixed methods approach to describe longitudinal changes in vaccine acceptance and to explore factors associated with parental coronavirus 2019 (COVID-19) vaccine hesitancy. We recruited parents who had children aged 6 months to 11 years old from five facilities in Japan. Two cross-sectional online surveys and semi-structured online interviews were conducted. Logistic regression analysis was used to explore factors associated with parents' vaccine hesitancy for their children, and thematic analysis was used to analyze the interview data.

RESULTS

In total, 134 parents responded to both online surveys and, of those, 10 participated in interviews. Acceptance rates of COVID-19 vaccination for their children were 19.4% (26/134) at the first survey and 11.2% (15/134) at the second survey. Integration of the data identified that the main factors for vaccine hesitancy included vaccine safety, vaccine effectiveness, government policy, and recommendations from people close to parents.

CONCLUSIONS

Readily available and more balanced information, and community-wide support from people close to parents and familiar health-care providers are likely to provide better support for parents' decision-making. Further investigation is required on how to provide information in an easily understood manner.

A Review of Parental Vaccine Hesitancy for Human Papillomavirus in Japan

Globally, Japan has the lowest rate of vaccine confidence. The persistent parental vaccine hesitancy has been attributed to safety and efficacy concerns and is primarily driven by the negative experience with human papillomavirus (HPV) vaccines. This literature review aimed to identify factors associated with HPV vaccine uptake and potential strategies to reduce vaccine hesitancy among Japanese parents. Articles published in English or Japanese between January 1998 and October 2022 that examined Japanese parental factors for HPV vaccine uptake were identified from PubMed, Web of Science, and Ichushi-Web. In total, 17 articles met the inclusion criteria. Four key themes which affected HPV vaccine hesitancy and acceptance were identified: perceptions of risk and benefits, trust and recommendation, information and knowledge, and sociodemographic characteristics. While governmental and healthcare provider recommendations are important factors, efforts to improve parental confidence in the HPV vaccine are required. Future interventions to counteract HPV vaccine hesitancy should actively disseminate information on vaccine safety and effectiveness, along with information on the severity and susceptibility of HPV infection.

Assessing the Level of Knowledge, Beliefs and Acceptance of HPV Vaccine: A Cross-Sectional Study in Romania

(1) Background: The infection with Human papilloma virus (HPV) is the most common sexually transmitted infection and it has been associated with cervical cancer (CC) in 99.7% of the cases. In Romania, CC is the second most common, with incidence (22.6%₀₀₀) and mortality rates (9.6%₀₀₀) three times higher than any other European country. Our aim was to assess the level of knowledge regarding HPV infection among parents, highschool students, medical students and doctors, with an emphasis on their main source of information—the Internet. (2) Methods: We applied five questionnaires to six categories of respondents: parents of pupils in the 6th–8th grades, medical students, doctors, boys in the 11th–12th grades, girls in the 11th–12th grades and their mothers. (3) Results: We included a total of 3108 respondents. 83.83% of all respondents had known about HPV infection. The level of information about HPV infection and vaccination was either satisfactory, poor or very poor. Their main source of information varied depending on the respondent profile and professional activity. Medical students were informed by doctors and healthcare professionals (53.0%), doctors gathered their information from books, journals and specialized brochures (61.6%). For the other categories of respondents, the Internet was the main source of information. Most respondents answered that doctors and healthcare professionals should provide information on HPV infection and vaccination, but very few of them actually seeked information from their general practitioner. (4) Conclusions: Population adherence to the appropriate preventative programs, as well as relevant information disseminated by the medical staff are key elements towards reducing the risk of HPV-associated cancers. An important role could also be played by schools, where teachers and school doctors could provide relevant information on the general aspects of HPV infection. Additionally, sex education classes and parent-teacher meetings should cover the main characteristics of HPV infection and what preventative measures can be employed against it.

Readability assessment of vaccine information: A systematic review for addressing vaccine hesitancy

OBJECTIVE

Vaccine hesitancy is a problem attracting growing attention and concern. Communication can be an effective tool to counteract vaccine hesitancy and promote optimal vaccine uptake. Readability has been recognized as one of the more important aspects of health communication for achieving good health literacy. We reviewed studies of readability assessment in the area of vaccine communication.

METHODS

We conducted a systematic literature search in September 2020, using four online databases (Medline, CINAHL, PsycArticles, and PsycINFO). We included studies that assessed the readability level of online and offline vaccine information materials.

RESULTS

We found 12 articles that were appropriate for inclusion. Ten of the studies were published after 2016. The readability levels of the majority of the materials assessed were found to be difficult and higher than 8th-grade level.

CONCLUSION

Readability assessments of vaccine information are scarce. The limited evidence shows that the readability level of vaccine information supplied by health care providers is more difficult to read than recommended. More studies on the readability of vaccine information are recommended.

PRACTICE IMPLICATIONS

Difficulty reading vaccine information may influence attitudes toward acceptance of or hesitancy to take vaccines. It is recommended that health care professionals use guidelines and tools to create easy-to-read vaccine information.

LOCO: The 88-million-word language of conspiracy corpus

The spread of online conspiracy theories represents a serious threat to society. To understand the content of conspiracies, here we present the language of conspiracy (LOCO) corpus. LOCO is an 88-million-token corpus composed of topic-matched conspiracy (N = 23,937) and mainstream (N = 72,806) documents harvested from 150 websites. Mimicking internet user behavior, documents were identified using Google by crossing a set of seed phrases with a set of websites. LOCO is hierarchically structured, meaning that each document is cross-nested within websites (N = 150) and topics (N = 600, on three different resolutions). A rich set of linguistic features (N = 287) and metadata includes upload date, measures of social media engagement, measures of website popularity, size, and traffic, as well as political bias and factual reporting annotations. We explored LOCO's features from different perspectives showing that documents track important societal events through time (e.g., Princess Diana's death, Sandy Hook school shooting, coronavirus outbreaks), while patterns of lexical features (e.g., deception, power, dominance) overlap with those extracted from online social media communities dedicated to conspiracy theories. By computing within-subcorpus cosine similarity, we derived a subset of the most representative conspiracy documents (N = 4,227), which, compared to other conspiracy documents, display prototypical and exaggerated conspiratorial language and are more frequently shared on Facebook. We also show that conspiracy website users navigate to websites via more direct means than mainstream users, suggesting confirmation bias. LOCO and related datasets are freely available at https://osf.io/snpcg/ .

Readability Assessment of HPV Vaccination and Cervical Cancer Information: A Systematic Scoping Review

It is important to provide information on HPV vaccination and on early detection and early treatment for cervical cancer. Readability is a key aspect in the success of cancer communication using written health information. We reviewed studies assessing the readability of information on HPV vaccination and cervical cancer. We conducted a systematic literature search in June 2021 using four online databases (Medline, CINAHL, PsycArticles, and PsycINFO). Studies that assessed the readability level of online and offline information regarding HPV vaccination and cervical cancer were included in the review. Twelve articles were deemed fit for study inclusion. Our results showed that most of the materials assessed were difficult to read and higher than eighth-grade reading level. Few of the materials assessed were at the recommended grade 5-6 level or below. Readability assessments of HPV vaccination and cervical cancer information are scarce. Additional studies on the readability of information regarding HPV vaccination and cervical cancer are recommended. Health professionals should develop health information on HPV vaccination and cervical cancer that is easy to read.

Lessons Learned from a Writing to Learn Program for Public Health Students at the University of Tokyo

We have taught writing for public health to students completing a Master of Public Health since 2016 in Japan. We adopted a writing-to-learn approach and assigned work to students to write health materials that encourage recipients to perform health behaviors (eg, drafting a poster to encourage lay audiences to adopt preventive behaviors during the COVID-19 pandemic). We collected students' work assignments and products from 2016 to 2020 and reviewed them to identify distinctive trends common to all years. We found that there was a curse of knowledge (ie, difficulties to imagine the state of mind of not knowing when knowing something) among students. Students strongly embraced the adage "knowledge is power" and underestimated the difficulties lay audiences face. Their writing was somewhat dogmatic, whereby experts imparted privileged knowledge to ignorant non-experts. However, it is well known that merely imparting knowledge often does not work to educate lay audiences about making better decisions. Debiasing this curse of knowledge among students will be the main target of our writing education.

Influence of high versus low readability level of written health information on self-efficacy: A randomized controlled study of the processing fluency effect

We investigated the relationship of processing fluency of written information about exercise to participants’ perceived interest, safety, self-efficacy, outcome expectation, and behavioral intention regarding the exercise. We randomly assigned 400 men and women aged 40–69 years to control or intervention conditions. Perceived self-efficacy of performing the exercise in the intervention group (i.e. easy to read) was significantly higher than that in the control group (i.e. difficult to read) (p = 0.04). Easy-to-read written health information may be important not only for making written health information comprehensible but also for increasing readers’ self-efficacy for adopting health-related behaviors.

The Easier the Better? Comparing the Readability and Engagement of Online Pro- and Anti-Vaccination Articles

Online anti-vaccine articles contribute to the anti-vaccine movement, which leads to recent outbreaks of vaccine-preventable diseases. Previous studies indicate that anti-vaccine articles are easy to read and understand, which may increase their abilities to engage viewers. The present study aims to examine if readability levels are related to engagement. Using combination of terms to search for vaccine articles in Google in May 2017, this study examined 541 pro-vaccine online articles with a total of 508,571 words and 382 anti-vaccine articles with a total of 843,805 words. Almost all vaccine articles exceeded the American average reading comprehension level. No significant difference in readability was found between pro- and anti-vaccine articles. Pro-vaccine articles that could only be understood by college graduates were less engaging than those with lower readability levels. No significant relationship between anti-vaccine articles’ readability and engagement was discovered. Different vaccine topics had different readability and engagement levels, which implied that certain combinations of themes and readability levels could enhance the health messages’ persuasion effect. Recommendations for designing effective health messages are provided.

Japanese anti- versus pro-influenza vaccination websites: a text-mining analysis

Anti-vaccination sentiment exists worldwide and Japan is no exception. Health professionals publish pro-influenza vaccination messages online to encourage proactive seeking of influenza vaccination. However, influenza vaccine coverage among the Japanese population is less than optimal. The contents of pro- and anti-influenza vaccination websites may contribute to readers' acceptance of one or the other position. We aimed to use a text-mining method to examine frequently appearing content on websites for and against influenza vaccination. We conducted online searches in January 2017 using two major Japanese search engines (Google Japan and Yahoo! Japan). Targeted websites were classified as 'pro', 'anti' or 'neutral' depending on their claims, with author(s) classified as 'health professionals', 'mass media' or 'laypersons'. Text-mining analysis was conducted, and statistical analysis was performed using a chi-squared test. Of the 334 websites analyzed, 13 content topics were identified. The three most frequently appearing content topics on pro-vaccination websites were vaccination effect for preventing serious cases of influenza, side effects of vaccination, and efficacy rate of vaccination. The three most frequent topics on anti-vaccination websites were ineffectiveness of influenza vaccination, toxicity of vaccination, and side effects of vaccination. The main disseminators of each topic, by author classification, were also revealed. We discuss possible tactics of online influenza vaccination promotion to counter anti-vaccination websites.

Amount of Narratives Used on Japanese Pro- and Anti-HPV Vaccination Websites: A Content Analysis

Background:

HPV vaccination is an effective way in preventing cervical cancer. However, HPV vaccination coverage rate has fallen to only a few percent in Japan. Anti HPV-vaccination websites often use narratives of those who have experienced adverse reactions to HPV vaccine to enhance their persuasiveness. Scholars suggest using the same medium to promote HPV vaccination online; e.g., presenting narratives of those who have experienced cervical cancer. We examined the amount of narratives used on Japanese pro- and anti-HPV vaccination websites.

Methods:

We conducted online searches using two major search engines (Googl.jp and Yahoo!.jp). Identified websites were classified as “pro,” “anti,” or “neutral” depending on their claims. Two independent raters coded the pro and anti websites and counted the number of narratives of people who experienced side effects of HPV vaccine or cervical cancer.

Results:

A total 26% of anti websites posted narratives on side effects. No pro websites posted narratives about having cervical cancer.

Conclusion:

Pro-HPV vaccination websites is recommended to post narratives to enhance the persuasiveness of their arguments.

A content analysis of HPV vaccination messages available online

Parents have varied HPV vaccine communication needs, which presents a challenge for healthcare providers. To improve communication resources for providers, we sought to characterize HPV vaccination messages available in existing educational materials. In fall 2016, we searched PubMed, educational material clearinghouses, and Google for English language HPV vaccination messages. We extracted messages that a provider might use when raising the topic of HPV vaccination, answering common questions, and motivating vaccination. Two reviewers independently coded each message. The search identified 267 unique messages about HPV vaccination. Messages generally were long (mean no. of words = 44, standard deviation [SD] = 33) and required a high level of education to read (mean reading grade level = 10, SD = 3). Only 32% of messages were shorter than 25 words, and 12% had a readability at or below grade 6. Most frequent were messages to address common parent questions or concerns (62%); the most common topics were diseases prevented by HPV vaccine (18%) and safety and side effects (16%). Many messages included information about cancer prevention (26%) and same-day vaccination (13%). Few messages (6%) used a presumptive style to recommend HPV vaccination. In conclusion, available messages about HPV vaccination were markedly varied. We identified few messages that were both brief (to facilitate providers memorizing them) and accessible (to facilitate parents understanding them). Future research should identify which messages lead to HPV vaccine uptake.

Readability of online information about HPV Immunization

The human papillomavirus (HPV) vaccine is highly effective in preventing anogenital cancers, but vaccination rates in the United States remain low. In deciding whether to vaccinate their children, parents are increasingly using the internet to gather information. This study aimed to examine the level of readability of information on HPV vaccines written on 100 websites that were found via an internet search. To create the website sample, the first 50 websites from the search "HPV immunization" were recorded, followed by the first 50 non-duplicated websites from the search "Gardasil." The content of the sites was analyzed using established readability scales. Websites were compared based on keyword search and on whether they had a commercial or non-commercial URL extension. The majority of websites were found to have information of a difficult reading level. Websites with commercial URL extensions and websites found using the search "Gardasil" had higher mean readability scores. These results suggest that many parents may not understand the information currently presented on the internet and that interventions aimed at improving the readability of online information could help to increase parental approval of the vaccine.

A qualitative analysis of the beliefs of Japanese anti-influenza vaccination website authors

Background

Influenza vaccine coverage among the Japanese population is less than optimal. Anti-vaccination sentiment exists worldwide, and Japan is no exception. Anti-influenza vaccination activists argue on the internet that influenza vaccine has little or no efficacy and a high risk of side effects, and they warn that people should forgo vaccination. We conducted a qualitative analysis to explore beliefs underlying the messages of anti-influenza vaccination websites, by focusing on the perceived value these beliefs provide to those who hold them.

Methods

We conducted online searches in January 2017 using two major Japanese search engines (Google Japan and Yahoo! Japan). Targeted websites were classified as “pro”, “anti”, or “neutral” depending on their claims. We applied a dual analytic approach—inductive thematic analysis and deductive interpretative analysis—to textual data of the anti websites.

Results

Of the 113 anti websites, we identified two themes that correspond to beliefs: it is necessary to 1) protect others against risks and exploitation related to influenza vaccination, and 2) educate others about hidden truths and self-determination. Authors of anti websites ascribed two values (people's “safety” and one's own “self-esteem”) to their beliefs.

Discussion

Website authors may engage in anti-vaccination activities because they want to feel they are virtuous, saving people from harm caused by vaccination, and to boost their self-esteem, thinking “I am enlightening uninformed people.” The anti-vaccination beliefs of website authors were considered to be strong. In promoting vaccination, it would be better not to target outright vaccine refusers, such as the authors of anti-vaccination websites; it is preferable to target vaccine-hesitant people who are more amenable to changing their attitudes toward vaccination. We discuss possible means of promoting vaccination in that target population.

Persuasiveness of Statistics and Patients' and Mothers' Narratives in Human Papillomavirus Vaccine Recommendation Messages: A Randomized Controlled Study in Japan

Background

The human papillomavirus (HPV) vaccination percentage among age-eligible girls in Japan is only in the single digits. This signals the need for effective vaccine communication tactics. This study aimed to examine the influence of statistical data and narrative HPV vaccination recommendation massages on recipients’ vaccination intentions.

Methods

This randomized controlled study covered 1,432 mothers who had daughters aged 12–16 years. It compared message persuasiveness among four conditions: statistical messages only; narrative messages of a patient who experienced cervical cancer, in addition to statistical messages; narrative messages of a mother whose daughter experienced cervical cancer, in addition to statistical messages; and a control. Vaccination intentions to have one’s daughter(s) receive the HPV vaccine before and after reading intervention materials were assessed. Statistical analysis was conducted using analysis of variance with Tukey’s test or Games–Howell post hoc test, and analysis of covariance with Bonferroni correction.

Results

Vaccination intentions after intervention in the three intervention conditions were higher than the control condition (p < 0.001). A mother’s narrative messages in addition to statistical messages increased HPV vaccination intention the most of all tested intervention conditions. A significant difference in the estimated means of intention with the covariate adjustment for baseline value (i.e., intention before intervention) was found between a mother’s narrative messages in addition to statistical messages and statistical messages only (p = 0.040).

Discussion

Mothers’ narrative messages may be persuasive when targeting mothers for promoting HPV vaccination. This may be because mothers can easily relate to and identify with communications from other mothers. However, for effective HPV vaccine communication, further studies are needed to understand more about persuasive differences in terms of statistics, narratives, and narrators. Directions for future research are also suggested.

Contents of Japanese pro- and anti-HPV vaccination websites: A text mining analysis

OBJECTIVE

In Japan, the human papillomavirus (HPV) vaccination rate has sharply fallen to nearly 0% due to sensational media reports of adverse events. Online anti-HPV-vaccination activists often warn readers of the vaccine's dangers. Here, we aimed to examine frequently appearing contents on pro- and anti-HPV vaccination websites.

METHODS

We conducted online searches via two major search engines (Google Japan and Yahoo! Japan). Targeted websites were classified as "pro," "anti," or "neutral" according to their claims, with the author(s) classified as "health professionals," "mass media," or "laypersons." We then conducted a text mining analysis.

RESULTS

Of the 270 sites analyzed, 16 contents were identified. The most frequently appearing contents on pro websites were vaccine side effects, preventable effect of vaccination, and cause of cervical cancer. The most frequently appearing contents on anti websites were vaccine side effects, vaccine toxicity, and girls who suffer from vaccine side effects. Main disseminators of each content according to the author's expertise were also revealed.

CONCLUSION

Pro-HPV vaccination websites should supplement deficient contents and respond to frequent contents on anti-HPV websites.

PRACTICE IMPLICATIONS

Effective tactics are needed to better communicate susceptibility to cervical cancer, frequency of side effects, and responses to vaccine toxicity and conspiracy theories.